2021 Sibanye-Stillwater Employee Benefits Notices & Forms - Content
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2021 Sibanye-Stillwater Employee Benefits Notices & Forms
Medicare Part D Creditable Coverage Notice
Important Notice from Sibanye-Stillwater Mining Company
About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it.
This notice has information about your current prescription drug
coverage with Sibanye-Stillwater Mining Company (the “Plan
Sponsor”) and about your options under Medicare’s prescription drug
coverage. This information can help you decide whether or not you
want to join a Medicare drug plan. If you are considering joining, you
should compare your current coverage, including which drugs are
covered at what cost, with the coverage and costs of the plans
offering Medicare prescription drug coverage in your area.
Information about where you can get help to make decisions about
your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current
coverage and Medicare’s prescription drug coverage:
(1) Medicare prescription drug coverage became available in 2006
to everyone with Medicare. You can get this coverage if you
join a Medicare Prescription Drug Plan or join a Medicare
Advantage Plan (like an HMO or PPO) that offers prescription
drug coverage. All Medicare drug plans provide at least a
standard level of coverage set by Medicare. Some plans may
also offer more coverage for a higher monthly premium.
(2) The Plan Sponsor has determined that the prescription drug
coverage offered by the Stillwater Mining Company Bargaining
Unit Health Plan and Stillwater Mining Company Health Plan is,
on average for all plan participants, expected to pay out as
2much as standard Medicare prescription drug coverage pays
and is therefore considered Creditable Coverage. Because
your existing coverage is Creditable Coverage, you can keep
this coverage and not pay a higher premium (a penalty) if you
later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for
Medicare and each year from October 15th to December 7th.
However, if you lose your current creditable prescription drug
coverage, through no fault of your own, you will also be eligible for a
two (2) month Special Enrollment Period (SEP) to join a Medicare
drug plan.
What Happens To Your Current Coverage If You Decide to Join
A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current Plan Sponsor
coverage may be affected. Moreover, if you do decide to join a
Medicare drug plan and drop your current Plan Sponsor coverage,
be aware that you and your dependents may not be able to get this
coverage back.
Please contact the person listed at the end of this notice for more
information about what happens to your coverage if you enroll in a
Medicare Part D prescription Drug Plan.
When Will You Pay A Higher Premium (Penalty) To Join A
Medicare Drug Plan?
You should also know that if you drop or lose your current coverage
with the Plan Sponsor and don’t join a Medicare drug plan within 63
3continuous days after your current coverage ends, you may pay a
higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription
drug coverage, your monthly premium may go up by at least 1% of
the Medicare base beneficiary premium per month for every month
that you did not have that coverage. For example, if you go nineteen
months without creditable coverage, your premium may consistently
be at least 19% higher than the Medicare base beneficiary premium.
You may have to pay this higher premium (a penalty) as long as you
have Medicare prescription drug coverage. In addition, you may
have to wait until the following October to join.
For More Information about This Notice or Your Current
Prescription Drug Coverage…
Contact the person listed below for further information. NOTE: You’ll
get this notice each year. You will also get it before the next period
you can join a Medicare drug plan, and if this coverage through the
Plan Sponsor changes. You also may request a copy of this notice at
any time.
For More Information about Your Options under Medicare
Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription
drug coverage is in the “Medicare & You” handbook. You’ll get a copy
of the handbook in the mail every year from Medicare. You may also
be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
o Visit www.medicare.gov.
o Call your State Health Insurance Assistance Program (see the
inside back cover of your copy of the “Medicare & You”
4handbook for their telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227). TTY users should
call 1-877-486-2048.
If you have limited income and resources, extra help paying for
Medicare prescription drug coverage is available. For information
about this extra help, visit Social Security on the web at
www.socialsecurity.gov or call them at 1-800-772-1213 (TTY 1-800-
325-0778).
Remember: Keep this Creditable Coverage notice. If you decide
to join one of the Medicare drug plans, you may be required to
provide a copy of this notice when you join to show whether or
not you have maintained creditable coverage and, therefore,
whether or not you are required to pay a higher premium (a
penalty).
Date: 10/15/2020
Name of Entity/Sender: Sibanye-Stillwater Mining
Company
Contact-Position/Office: Human Resources Manager
Address: 536 East Pike Ave PO Box 1330,
Columbus, MT 59019
Phone Number: 406-322-8930
56
CHIPRA/CHIP Notice
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state
may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If
you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you
may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit
www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State
Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might
be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or
www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the
premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer
plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special
enrollment“ opportunity, and you must request coverage within 60 days of being determined eligible for premium
assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at
www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan
premiums. The following list of states is current as of January 31, 2021 Contact your State for more information on
eligibility –
COLORADO – Health First Colorado (Colorado’s
ALABAMA – Medicaid
Medicaid Program) & Child Health Plan Plus (CHP+)
Health First Colorado Website:
https://www.healthfirstcolorado.com/
Health First Colorado Member Contact Center:
1-800-221-3943/ State Relay 711
CHP+: https://www.colorado.gov/pacific/hcpf/child-health-
Website: http://myalhipp.com/
plan-plus
Phone: 1-855-692-5447
CHP+ Customer Service: 1-800-359-1991/ State Relay 711
Health Insurance Buy-In Program (HIBI):
https://www.colorado.gov/pacific/hcpf/health-insurance-buy-
program
HIBI Customer Service: 1-855-692-6442
ALASKA – Medicaid FLORIDA – Medicaid
The AK Health Insurance Premium Payment Program
Website: http://myakhipp.com/ Website:
Phone: 1-866-251-4861 https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.
Email: CustomerService@MyAKHIPP.com com/hipp/index.html
Medicaid Eligibility: Phone: 1-877-357-3268
http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
ARKANSAS – Medicaid GEORGIA – Medicaid
Website: https://medicaid.georgia.gov/health-insurance-
Website: http://myarhipp.com/
premium-payment-program-hipp
Phone: 1-855-MyARHIPP (855-692-7447)
Phone: 678-564-1162 ext 2131
CALIFORNIA – Medicaid INDIANA – Medicaid
Healthy Indiana Plan for low-income adults 19-64
Website:
Website: http://www.in.gov/fssa/hip/
Health Insurance Premium Payment (HIPP) Program
Phone: 1-877-438-4479
http://dhcs.ca.gov/hipp
All other Medicaid
Phone: 916-445-8322
Website: https://www.in.gov/medicaid/
Email: hipp@dhcs.ca.gov
Phone 1-800-457-4584
7IOWA – Medicaid and CHIP (Hawki) MONTANA – Medicaid
Medicaid Website:
https://dhs.iowa.gov/ime/members
Medicaid Phone: 1-800-338-8366
Hawki Website:
Website:
http://dhs.iowa.gov/Hawki
http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Hawki Phone: 1-800-257-8563
Phone: 1-800-694-3084
HIPP Website:
https://dhs.iowa.gov/ime/members/medicaid-a-to-
z/hipp
HIPP Phone: 1-888-346-9562
KANSAS – Medicaid NEBRASKA – Medicaid
Website: http://www.ACCESSNebraska.ne.gov
Website: https://www.kancare.ks.gov/ Phone: 1-855-632-7633
Phone: 1-800-792-4884 Lincoln: 402-473-7000
Omaha: 402-595-1178
KENTUCKY – Medicaid NEVADA – Medicaid
Kentucky Integrated Health Insurance Premium
Payment Program (KI-HIPP) Website:
https://chfs.ky.gov/agencies/dms/member/Pages/kihipp
.aspx
Phone: 1-855-459-6328
Email: KIHIPP.PROGRAM@ky.gov Medicaid Website: http://dhcfp.nv.gov
Medicaid Phone: 1-800-992-0900
KCHIP Website:
https://kidshealth.ky.gov/Pages/index.aspx
Phone: 1-877-524-4718
Kentucky Medicaid Website: https://chfs.ky.gov
LOUISIANA – Medicaid NEW HAMPSHIRE – Medicaid
Website: www.medicaid.la.gov or Website: https://www.dhhs.nh.gov/oii/hipp.htm
www.ldh.la.gov/lahipp Phone: 603-271-5218
Phone: 1-888-342-6207 (Medicaid hotline) or 1-855- Toll free number for the HIPP program: 1-800-852-
618-5488 (LaHIPP) 3345, ext 5218
MAINE – Medicaid NEW JERSEY – Medicaid and CHIP
Enrollment Website:
https://www.maine.gov/dhhs/ofi/applications-forms
Medicaid Website:
Phone: 1-800-442-6003
http://www.state.nj.us/humanservices/
TTY: Maine relay 711
dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
Private Health Insurance Premium Webpage:
CHIP Website: http://www.njfamilycare.org/index.html
https://www.maine.gov/dhhs/ofi/applications-forms
CHIP Phone: 1-800-701-0710
Phone: -800-977-6740.
TTY: Maine relay 711
MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid
Website: https://www.mass.gov/info- Website:
details/masshealth-premium-assistance-pa https://www.health.ny.gov/health_care/medicaid/
Phone: 1-800-862-4840 Phone: 1-800-541-2831
MINNESOTA – Medicaid NORTH CAROLINA – Medicaid
Website:
https://mn.gov/dhs/people-we-serve/children-and-
Website: https://medicaid.ncdhhs.gov/
families/health-care/health-care-programs/programs-
Phone: 919-855-4100
and-services/other-insurance.jsp
Phone: 1-800-657-3739
8MISSOURI – Medicaid NORTH DAKOTA – Medicaid
Website:
Website:
http://www.dss.mo.gov/mhd/participants/pages/hipp.ht
http://www.nd.gov/dhs/services/medicalserv/medicaid/
m
Phone: 1-844-854-4825
Phone: 573-751-2005
OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIP
Medicaid Website: https://medicaid.utah.gov/
Website: http://www.insureoklahoma.org
CHIP Website: http://health.utah.gov/chip
Phone: 1-888-365-3742
Phone: 1-877-543-7669
OREGON – Medicaid VERMONT– Medicaid
Website: http://healthcare.oregon.gov/Pages/index.aspx
Website: http://www.greenmountaincare.org/
http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-250-8427
Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIP
Website:
Website: https://www.coverva.org/hipp/
https://www.dhs.pa.gov/providers/Providers/Pages/Medi
Medicaid Phone: 1-800-432-5924
cal/HIPP-Program.aspx
CHIP Phone: 1-855-242-8282
Phone: 1-800-692-7462
RHODE ISLAND – Medicaid and CHIP WASHINGTON – Medicaid
Website: http://www.eohhs.ri.gov/
Website: https://www.hca.wa.gov/
Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte
Phone: 1-800-562-3022
Share Line)
SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid
Website: https://www.scdhhs.gov Website: http://mywvhipp.com/
Phone: 1-888-549-0820 Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN – Medicaid and CHIP
Website:
Website: http://dss.sd.gov https://www.dhs.wisconsin.gov/badgercareplus/p-
Phone: 1-888-828-0059 10095.htm
Phone: 1-800-362-3002
TEXAS – Medicaid WYOMING – Medicaid
Website:
Website: http://gethipptexas.com/ https://health.wyo.gov/healthcarefin/medicaid/programs-
Phone: 1-800-440-0493 and-eligibility/
Phone: 1-800-251-1269
To see if any other states have added a premium assistance program since January 31, 2021, or for more information on special
enrollment rights, contact either:
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
U.S. Department of Labor U.S. Department of Health and Human Services
www.dol.gov/agencies/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
9Annual Notice of Women’s Health and Cancer Rights Act Do you know that your plan, as required by the Women’s Health and Cancer Right Act of 1998, provides benefits for mastectomy-related services, including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses and treatment for complications resulting from a mastectomy, including lymphedema? Call your plan administrator at 406-322-8930 for more information. 10
Wellness Program Disclosure HIPAA Wellness Notice Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all participants. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact Shannon Arthur, Human Resources Manager, at 536 East Pike Ave PO Box 1330, Columbus, MT 59019, 406-322-8930, shannon.arthur@sibanyestillwater.com and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status, if you are eligible for an alternate standard. EEOC Wellness Notice Sibanye-Stillwater Voluntary Wellness Program is a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. You and your spouse are not required to participate in the Sibanye-Stillwater Voluntary Wellness Program However, employees and spouses who choose to participate will receive a financial incentive. Only employees and spouses who participate will receive the financial incentive. The participation of employees and spouses will be treated separately. From time to time, additional incentives, such as gift cards and other monetary and nonmonetary awards, may be available for employees and spouses who participate in certain health-related activities or achieve certain health outcomes. If you, and/or your spouse, are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive, you and/or your spouse may be entitled to a reasonable alternative standard. You or your spouse may request a reasonable alternative standard by contacting Human Resources. Your results will be used to provide you with information to help you understand your current health and potential risks, and may also be used to offer you services through the wellness program, such as Health education and wellness coaching. You also are encouraged to share your results or concerns with your own doctor. Wellness Incentives Employees who participate in Sibanye-Stillwater wellness program may receive a credit that can be used to offset the cost of benefits. The wellness credit may be subject to change based on your or your spouse’s participation in the Company’s wellness program. Sibanye-Stillwater may automatically apply or discontinue the wellness credit based on your or your spouse’s compliance with the wellness program’s requirements in effect from time to time. 11
Protections from Disclosure of Medical Information Sibanye-Stillwater and its partners are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program and Sibanye-Stillwater Mining Company may use aggregate information it collects to design a program based on identified health risks in the workplace, Sibanye-Stillwater Voluntary Wellness Program will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment. Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information are health care providers in order to provide you with services under the wellness program. In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately. You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate. If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact Shannon Arthur, Human Resources Manager at 536 East Pike Ave PO Box 1330, Columbus, MT 59019, 406-322-8930, shannon.arthur@sibanyestillwater.com. 12
Notice of Availability of HIPAA Notice of Privacy Practices Sibanye-Stillwater Mining Company 536 East Pike Ave PO Box 1330, Columbus, MT 59019 10/15/2020 To: Participants in the Stillwater Mining Company Bargaining Unit Health Plan and Stillwater Mining Company Salaried Health Plan From: Shannon Arthur, Human Resources Manager Re: Availability of Notice of Privacy Practices The Stillwater Mining Company Health Plan (each a “Plan”) maintains a Notice of Privacy Practices that provides information to individuals whose protected health information (PHI) will be used or maintained by the Plan. If you would like a copy of the Plan's Notice of Privacy Practices, please contact Shannon Arthur, HIPAA Officer at 536 East Pike Ave PO Box 1330, Columbus, MT 59019, 406-322-8930, shannon.arthur@sibanyestillwater.com. 13
Patient Protection Disclosures Stillwater Mining Company Bargaining Unit Health Plan and Stillwater Mining Company Salaried Health Plan generally require the designation of a primary care provider for the EPO plans. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from Stillwater Mining Company Bargaining Unit Health Plan or Stillwater Mining Company Salaried Health Plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the Shannon Arthur, Human Resources Manager at 536 East Pike Ave PO Box 1330, Columbus, MT 59019, 406-322-8930, shannon.arthur@sibanyestillwater.com. 14
Notice of Marketplace Coverage Options
New Health Insurance Marketplace Coverage
Options and Your Health Coverage
PART A: General Information
When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace.
To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and
employmentbased health coverage offered by your employer.
What is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop
shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly
premium right away. Open enrollment for health insurance coverage through the Marketplace begins November 1, 2020 for coverage starting
January 1, 2021.
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that
doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through
the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly
premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets
certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5%
(as adjusted annually) of your household income for the year, or if the coverage your employer provides does not meet the "minimum value"
standard set by the Affordable Care Act, you may be eligible for a tax credit.1
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may
lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee
contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for
coverage through the Marketplace are made on an after-tax basis.
How Can I Get More Information?
For more information about your coverage offered by your employer, please check your summary plan description or contact. Shannon
Arthur, Human Resources Manager at 536 East Pike Ave PO Box 1330, Columbus, MT 59019, 406-322-8930,
shannon.arthur@sibanyestillwater.com.
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost.
Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a
Health Insurance Marketplace in your area.
1 An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs
covered by the plan is no less than 60 percent of such costs.
15Part B: Information About Health Coverage Offered by Your Employer
This section contains information about any health coverage offered by your employer. If you decide to complete an application for
coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace
3. Employer name 4. Employer Identification Number (EIN)
Sibanye-Stillwater Mining Company 81-0480654
5. Employer address, 7. City, 8. State, 9. Zip Code 6. Employer phone number
536 East Pike Ave PO Box 1330, Columbus, MT 59019 406-322-8930
10. Who can we contact about employee health coverage at this job?
Shannon Arthur, Human Resources Manager
11. Phone number (if different from above) 12. Email address
406-322-8930 shannon.arthur@sibanyestillwater.com
application.
Here is some basic informtion about health coverage offered by this employer:
o As your employer, we offer a health plan to:
☐ All employees. Eligible employees are:
☒ Some employees. Eligible employees are:
Full-Time employees regularly scheduled to work 30 or more hours per week.
o With respect to dependents:
☒ We do offer coverage. Eligible dependents are:
Your spouse, your natural child, stepchild, or adopted child, or other child for whom a court
holds you responsible. Children up to age 26 and Children age 26 and older who are physically
or mentally incapable of self-support and are on the plan prior to age 26.
☐ We do not offer coverage.
☒ If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable,
based on employee wages.
Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the
Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible
for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on
a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium
discount.
16Notice of Special Enrollment Rights
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health
insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if
you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or
your dependents’ other coverage). However, you must request enrollment no later than 31 Days after your or your
dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you
may be able to enroll yourself and your dependents. However, you must request enrollment no later than 31 Days
after the marriage, birth, adoption, or placement for adoption.
Effective April 1, 2009, if either of the following two events occur, you will have 60 Days after the date of the event
to request enrollment in your employer’s plan:
o Your dependents lose Medicaid or CHIP coverage because they are no longer eligible.
o Your dependents become eligible for a state’s premium assistance program.
To take advantage of special enrollment rights, you must experience a qualifying event and provide the employer
plan with timely notice of the event and your enrollment request. You must complete the necessary enrollment
forms and return them to Human Resources within 31 days following your qualifying Change in Status
event.
To request special enrollment or obtain more information, contact Sibanye-Stillwater Mining Company, Human
Resource Dept. at 406-322-8930.
17General COBRA Notice
General Notice of COBRA Continuation Coverage Rights
Continuation Coverage Rights Under COBRA
Introduction
You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has
important information about your right to COBRA continuation coverage, which is a temporary extension of coverage
under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and
your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you
may also become eligible for other coverage options that may cost less than COBRA continuation coverage.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members
of your family when group health coverage would otherwise end. For more information about your rights and
obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact
the Plan Administrator.
You may have other options available to you when you lose group health coverage. For example, you may be
eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the
Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally,
you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as
a spouse’s plan), even if that plan generally doesn’t accept late enrollees.
What is COBRA continuation coverage?
COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event.
This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event,
COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and
your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the
qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA
continuation coverage.
If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the
following qualifying events:
o Your hours of employment are reduced, or
o Your employment ends for any reason other than your gross misconduct.
If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan
because of the following qualifying events:
o Your spouse dies;
o Your spouse’s hours of employment are reduced;
o Your spouse’s employment ends for any reason other than his or her gross misconduct;
o Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
o You become divorced or legally separated from your spouse.
18Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the
following qualifying events:
o The parent-employee dies;
o The parent-employee’s hours of employment are reduced;
o The parent-employee’s employment ends for any reason other than his or her gross misconduct;
o The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
o The parents become divorced or legally separated; or
o The child stops being eligible for coverage under the Plan as a “dependent child.”
Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a
proceeding in bankruptcy is filed with respect to Sibanye-Stillwater Mining Company, and that bankruptcy results in the
loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified
beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified
beneficiaries if bankruptcy results in the loss of their coverage under the Plan.
When is COBRA continuation coverage available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been
notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying
events:
o The end of employment or reduction of hours of employment;
o Death of the employee;
o Commencement of a proceeding in bankruptcy with respect to the employer; or
o The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).
For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing
eligibility for coverage as a dependent child), you must notify the Plan Administrator within If Yes, Type Answer Here
after the qualifying event occurs. You must provide this notice to: Shannon Arthur. If Yes, Add description here
How is COBRA continuation coverage provided?
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be
offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA
continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and
parents may elect COBRA continuation coverage on behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to
employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the
initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.
There are also ways in which this 18-month period of COBRA continuation coverage can be extended:
Disability extension of 18-month period of COBRA continuation coverage
If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify
the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11
months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at
some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month
period of COBRA continuation coverage. If Yes, Add description here
Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse
and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a
maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be
19available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former
employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally
separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only
available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the
Plan had the first qualifying event not occurred.
Are there other coverage options besides COBRA Continuation Coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your
family through the Health Insurance Marketplace, Medicare, Medicaid, Children’s Health Insurance Program (CHIP), or
other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.”
Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these
options at www.healthcare.gov.
Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?
In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the
Medicare initial enrollment period, you have an 8-month special enrollment period 1 to sign up for Medicare Part A or B,
beginning on the earlier of
o The month after your employment ends; or
o The month after group health plan coverage based on current employment ends.
If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late
enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA
continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan
may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the
COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in
the other part of Medicare after the date of the election of COBRA coverage.
If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer)
and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are
not enrolled in Medicare.
For more information visit https://www.medicare.gov/medicare-and-you.
If you have questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or
contacts identified below. For more information about your rights under the Employee Retirement Income Security Act
(ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans,
contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security
Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and
District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit
www.HealthCare.gov.
Keep your Plan informed of address changes
To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members.
You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
Plan contact information
Allegiance COBRA Services, Allegiance COBRA Services at PO Box 2097, Missoula, MT 59806, 800-259-2738,
cobra@askallegiance.com.
1 https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b/part-a-part-b-sign-up-periods.
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